Provider Demographics
NPI:1942262019
Name:MERTZ, PERSILA V (MD)
Entity Type:Individual
Prefix:
First Name:PERSILA
Middle Name:V
Last Name:MERTZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:PA
Mailing Address - Zip Code:17522-2710
Mailing Address - Country:US
Mailing Address - Phone:717-733-3600
Mailing Address - Fax:717-721-3038
Practice Address - Street 1:115 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-2710
Practice Address - Country:US
Practice Address - Phone:717-733-3600
Practice Address - Fax:717-721-3038
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD043167E207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
110758OtherMEDICARE PTAN
PA5984190001OtherDMEPOS PTAN
110758OtherLEGACY NUMBER
PA093980OtherMEDICARE PROVIDER #
PA1093934655OtherGROUP NPI
110758OtherMEDICARE PTAN
PA110758Medicare Oscar/Certification